Cross sectional study of symptom attribution and recognition of depression and anxiety in primary care   Commentary: There must be limits to the medicalisation of human distress

OBJECTIVES: To examine the effect of patients' causal attributions of common somatic symptoms on recognition by general practitioners of cases of depression and anxiety and to test the hypothesis that normalising attributions make recognition less likely. DESIGN: Cross sectional survey. SETTING: One general practice of eight doctors in Bristol. SUBJECTS: 305 general practice attenders. MAIN OUTCOME MEASURE: The rate of detection by general practitioners of cases of depression and anxiety as defined by the general health questionnaire. RESULTS: Consecutive attenders completed the general health questionnaire and the symptom interpretation questionnaire, which scores style of symptom attribution along the dimensions of psychologising, somatising, and normalising. General practitioners detected depression or anxiety in 56 (36%; 95% confidence interval 28% to 44%) of the 157 patients who scored highly on the general health questionnaire. Subjects with a normalising attributional style were less likely to be detected as cases; doctors did not make any psychological diagnosis in 46 (85%; 73% to 93%) of 54 patients who had high questionnaire and high normalising scores. Those with a psychologising style were more likely to be detected; doctors did not detect 21 (38%; 25% to 52%) of 55 patients who had high questionnaire and high psychologising scores. The somatisation scale was not associated with low detection rates. This pattern of results persisted after adjustment for age, sex, general health questionnaire score, and general practitioner. CONCLUSIONS: Normalising attributions minimise symptoms and are non-pathological in character. The normalising attributional style is predominant in general practice attenders and is an important cause of low rates of detection of depression and anxiety.